Provider Demographics
NPI:1710123245
Name:BERNETT, PENNIE LYNN (BSW)
Entity Type:Individual
Prefix:
First Name:PENNIE
Middle Name:LYNN
Last Name:BERNETT
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:PENNIE
Other - Middle Name:LYNN
Other - Last Name:DWYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:814 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-1509
Mailing Address - Country:US
Mailing Address - Phone:608-633-0908
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3301
Practice Address - Country:US
Practice Address - Phone:888-742-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7457-120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator